MICHIGAN ISLAMIC ACADEMY

2301 Plymouth Road

Ann Arbor, MI 48105
734.665.8882
www.mia-aa.org

AND SAY: “MY LORD! INCREASE ME IN KNOWLEDGE!”

Third-Party Billing Authorization for Dual-Enrolled Students

Student’s Name: _____________________________________________ Birthdate/MIA Student ID ____________________________________

Student Instructions for Registration:

1. New students – complete the application for the college you will be dual-enrolled with. For help completing the application, please
contact the MIA school counselor. Returning students – skip to #2.
2. Register for classes – be sure to consult with the MIA school counselor prior to registering for courses.
3. Complete the “Registered Course(s)” section below.
4. Have your parent/legal guardian sign this form.
5. Turn the completed form back to your MIA school counselor.
6. The school district will complete the Authorized Reimbursement Amount section and mail this form to the address below.

NOTE: In order to avoid incurring additional fees, this form must be completed each semester that the student is dual-enrolled.

Registered Course(s):

Semester: _________________________ (indicate fall, winter, or spring AND the term year)

Classes
Authorized Reimbursement Amount

Course #/Title Credit Hours Percentage or $Amount

___________________________________ ________________ _____________________________

___________________________________ ________________ _____________________________
___________________________________ ________________ _____________________________
___________________________________ ________________ _____________________________
___________________________________ ________________ _____________________________

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I understand that I am responsible to pay for any charges incurred by my child that are NOT covered by the School District.

Parent/Guardian Name: ________________________________________________________________________________________

Parent or Legal Guardian Signature: ___________________________________________________Date: _______________________

This student is eligible to attend only the courses listed above and it is agreed that this School District will reimburse college institution for the
authorized amount.

Principal/Counselor Printed Name: ____________________________________________________________________________

Principal/Counselor Signature: _____________________________________________________Date: ______________________

Send invoice to:

School District _______________________________________________________________________

Attention _____________________________________________________________________________
Street Address _______________________________________________________________________
City/State/Zip ________________________________________________________________________
Telephone Number ___________________________________________________________________